Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation.

BACKGROUND: Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-COVID-19 viral ARDS patients has been reported, with increased bleeding rates in COVID-19 attributed to both intensified anticoagulation and a disease-specific endotheliopathy. We hypothesized that lower intensity of anticoagulation during VV ECMO would be associated with a lower risk of ICH. In a retrospective, multicenter study from three academic tertiary intensive care units, we included patients with confirmed COVID-19 ARDS requiring VV ECMO support from March 2020 to January 2022. Patients were grouped by anticoagulation exposure into higher intensity, targeting anti-factor Xa activity (anti-Xa) of 0.3-0.4 U/mL, versus lower intensity, targeting anti-Xa 0.15-0.3 U/mL, cohorts. Mean daily doses of unfractionated heparin (UFH) per kg bodyweight and effectively measured daily anti-factor Xa activities were compared between the groups over the first 7 days on ECMO support. The primary outcome was the rate of ICH during VV ECMO support. RESULTS: 141 critically ill COVID-19 patients were included in the study. Patients with lower anticoagulation targets had consistently lower anti-Xa activity values over the first 7 ECMO days (p < 0.001). ICH incidence was lower in patients in the lower anti-Xa group: 4 (8%) vs 32 (34%) events. Accounting for death as a competing event, the adjusted subhazard ratio for the occurrence of ICH was 0.295 (97.5% CI 0.1-0.9, p = 0.044) for the lower anti-Xa compared to the higher anti-Xa group. 90-day ICU survival was higher in patients in the lower anti-Xa group, and ICH was the strongest risk factor associated with mortality (odds ratio [OR] 6.8 [CI 2.1-22.1], p = 0.001). CONCLUSIONS: For COVID-19 patients on VV ECMO support anticoagulated with heparin, a lower anticoagulation target was associated with a significant reduction in ICH incidence and increased survival.

How we manage blood product support and coagulation in the adult patient requiring extracorporeal membrane oxygenation.

Use of extracorporeal membrane oxygenation (ECMO) is increasing among critically ill adults with cardiac and/or respiratory failure. Use of ECMO is associated with hemostatic alterations requiring use of anticoagulation and blood product support. There are limited guidelines to direct transfusion management in the adult patient supported with ECMO. The objective of this article is to describe (1) the role of the transfusion service in providing transfusion support and current understanding of transfusion thresholds, (2) the complexities of monitoring anticoagulation, and (3) the consideration regarding additional factor concentrates and antifibrinolytics within the context of ECMO support. The information provided should assist ECMO care teams in informing transfusion and anticoagulation practice while highlighting key areas for future research and collaboration.

Bridge with a left ventricular assist device to a simultaneous heart and kidney transplant: Review of the United Network for Organ Sharing database.

BACKGROUND: Left ventricular assist device (LVAD) implantation as a bridge to cardiac transplantation (BTT) is an effective treatment for end-stage heart failure patients. Currently, there is an increasing number of patients with a LVAD who need a heart and kidney transplant (HKT). Little is known of the prognostic outcomes in these patients. This study was undertaken to determine whether an equivalent outcome would be present in HKTs as compared to a non-LVAD primary HKT cohort. METHODS: We reviewed the United Network for Organ Sharing database from 2004 to 2013. Orthotropic heart transplant recipients (n = 49 799) were subcategorized as dual organ HKT (n = 1 921) and then divided into cohorts of HKT following continuous flow left ventricular assist device placement (CF-VAD-HKT, n = 113) or no LVAD placement (HKT, n = 1 808). Survival after transplantation was analyzed. RESULTS: For CF-LVAD-HKT and HKT cohorts, preoperative characteristics were similar regarding age (50.8 ± 13.7, 50.1 ± 13.7, p = 0.75) and panel reactive antibody (12.3 ± 18.4 vs 7.1 ± 18.4, p = 0.06). Donors were similar in age, gender, creatinine, and ejection fraction. Post-transplant, there was no difference in complications. Survival for CF-LVAD-HKT and HKT were similar at 1 year (77% vs 82%) and 3 years (75% vs 77%, log rank p = 0.2814). CONCLUSIONS: For patients with advanced heart failure and persistent renal dysfunction, simultaneous HKT is a safe option. Survival after CF-LVAD-HKT is equivalent to conventional HKT.